Mortality among people who have experienced homelessness: protocol for a systematic review and meta-analysis.

INTRODUCTION: Homelessness is a major contributor to health inequalities. People who experience homelessness are at markedly increased risk of multiple and complex health morbidities which likely increase their susceptibility to early, preventable death. Despite this, the mortality burden in this group remains poorly understood, limited in part by insufficient synthesis of data at a global level. This systematic review will synthesise international literature examining rates of risk and protective factors for mortality among people who have experienced homelessness. METHODS AND ANALYSIS: We will search MEDLINE, PsycINFO, Embase and PubMed for peer-reviewed cohort studies examining mortality among people who have experienced homelessness. No study eligibility restrictions will be placed on the date, country of origin, or language of publications, or age of the sample. We will assess the quality of included studies using the Methodological Standards for Epidemiological Research scale. Our measures of mortality will include: (A) incidence-all cause and cause specific, expressed as a crude mortality rate (CMR) per 1000 person-years, with 95% CI and (B) all cause and cause specific, indirectly standardised mortality ratios (SMRs) with 95%CI. Associations between risk and protective factors and all-cause and cause-specific mortality will be reported using pooled relative risk ratios with 95% CI. Where there are sufficient data, the influence of subgroup and methodological factors on CMRs, SMRs and predictive factors will be examined using meta-regression. ETHICS AND DISSEMINATION: This study does not require institutional ethics review or approval as it will synthesise findings from published studies that have previously been granted relevant ethics approvals. Study findings will be disseminated through a peer-reviewed journal article, conference and seminar presentations. A plain language summary will be distributed through the authors' academic and professional networks. PROSPERO REGISTRATION NUMBER: CRD42021272937.

The barriers of home environments for obesity prevention in Indonesian adolescents.

BACKGROUND: Obesity and its related cardiovascular-metabolic diseases are growing public health concerns. Despite global attention to obesity, its prevalence is steeply increasing in developing countries, especially in children and adolescents. Eating behaviours and physical activity are modifiable risk factors for obesity that can variably be shaped by families. Eating behaviours and physical activity are especially important during adolescence, given its significance as a foundational period for developing healthy lifestyles. This qualitative study aimed to explore barriers and opportunities around creating healthy lifestyles among adolescents in Indonesia, focussing on family environments from diverse socio-demographic backgrounds. METHOD: In-depth interviews using a semi-structured guide were undertaken with consecutively recruited 10-18-year-old adolescents with overweight or obesity, and their parents, from three different sites: urban (Jakarta, the capital city of Indonesia), peri-urban (West Java Province) and rural (Banten Province). Thematic analysis was used to identify patterns of meaning. RESULTS: Nineteen dyads were interviewed. Thematic analysis revealed four themes: limited knowledge of healthy lifestyles; healthy lifestyles not a concern of daily life; limited parenting skills, including inequity around gender roles; and aspects of availability and accessibility. These interconnected barriers influenced lifestyle practices at home within the context of daily preferences and decisions around food and activities. Gender role inequity and healthy food accessibility were more prominent in rural families than in those from urban or peri-urban settings. CONCLUSIONS: Healthy lifestyles in adolescence may be supported by strategies to enhance parenting skills, build individual motivation, and support the development of more enabling environments.

The Cumulative Effect of Multilevel Factors on Myopia Prevalence, Incidence, and Progression Among Children and Adolescents in China During the COVID-19 Pandemic.

Purpose: To estimate the effects of school closures and associated lifestyle changes on myopia in Chinese children and adolescents during the coronavirus disease 2019 (COVID-19) pandemic. Methods: Two cross-sectional surveys recruited 14,296 Chinese students aged 7 to 18 years in November 2019 and June 2020 from which an open cohort study (nested queue design) was derived and used to assess myopia prevalence, incidence, and progression rates (defined as students with progression in myopia severity at the second survey wave among those with myopia at baseline). The severity of myopia was determined by measurements of visual acuity (<5.0) and noncycloplegic refraction (spherical equivalent <-0.50 diopters). Twenty-three myopia-influencing factors were divided into three categories: eye-use habits, lifestyle, and family and subjective factors. Responses to each of these 23 factors were labeled as either positive or negative options and then combined to generate a comprehensive score. Results: Boys and girls were equally represented (50%) and had the same average age (11.5 years) at each wave. The myopia prevalence increased from 48.2% to 60.0%, with 27.1% myopia incidence and 13.2% myopia progression rates for Chinese children and adolescents. Each of the 23 factors was associated with myopia prevalence but had no significant effect on myopia incidence or progression. However, these 23 factors had a cumulative effect on myopia risks; higher scores were associated with more positive factors and lower risk ratios of myopia and vice versa. Except for the progression rate, the myopia prevalence and incidence and risk ratios decreased with higher comprehensive scores. Conclusions: School closures during the COVID-19 pandemic increased the risk of myopia in Chinese children and adolescents due to the accumulation of poor eyesight habits, unhealthy lifestyles, and excessive screen time. Translational Relevance: Rather than focusing on single risk factors for myopia, future myopia prevention strategies should focus on integrating multiple comprehensive approaches across schools, families, and communities.

Improving health and social systems for all children in LMICs: structural innovations to deliver high-quality services.

Despite health gains over the past 30 years, children and adolescents are not reaching their health potential in many low-income and middle-income countries (LMICs). In addition to health systems, social systems, such as schools, communities, families, and digital platforms, can be used to promote health. We did a targeted literature review of how well health and social systems are meeting the needs of children in LMICs using the framework of The Lancet Global Health Commission on high-quality health systems and we reviewed evidence for structural reforms in health and social sectors. We found that quality of services for children is substandard across both health and social systems. Health systems have deficits in care competence (eg, diagnosis and management), system competence (eg, timeliness, continuity, and referral), user experience (eg, respect and usability), service provision for common and serious conditions (eg, cancer, trauma, and mental health), and service offerings for adolescents. Education and social services for child health are limited by low funding and poor coordination with other sectors. Structural reforms are more likely to improve service quality substantially and at scale than are micro-level efforts. Promising approaches include governing for quality (eg, leadership, expert management, and learning systems), redesigning service delivery to maximise outcomes, and empowering families to better care for children and to demand quality care from health and social systems. Additional research is needed on health needs across the life course, health system performance for children and families, and large-scale evaluation of promising health and social programmes.

Impact of the coronavirus pandemic on anorexia nervosa and atypical anorexia nervosa presentations to an Australian tertiary paediatric hospital.

AIM: The coronavirus (COVID-19) pandemic has led to increased concerns about adolescent mental health. This study aimed to determine the effect of the pandemic on adolescent eating disorders (EDs) by measuring changes in the number and severity of presentations to an Australian paediatric ED service that utilises a standardised approach to triage and assessment. METHODS: A 4-year retrospective chart review (2017-2020) of all patients (n = 457) presenting to the Royal Children's Hospital Eating Disorder Service, Melbourne, was undertaken. The incidence of each diagnosis and measures of condition severity were extracted from the database and patient medical records. Clinical comments relating to the impact of COVID-19, on both ED behaviours and treatment, were also noted. RESULTS: Annual presentations increased from a mean of 98.7 per annum from 2017 to 2019 to 161 in 2020 (63% increase). COVID-19 restrictions were reported to be a trigger for ED behaviours in 40.4% of adolescents diagnosed with anorexia nervosa in 2020. There was no significant difference in severity across years despite increased cases. CONCLUSIONS: The dramatic increase in presentations has implications for primary health and paediatric care as well as specialist ED services. Increased support is needed for EDs during this time.

Evaluating quality in adolescent mental health services: a systematic review.

OBJECTIVES: To evaluate the quality of adolescent mental health service provision globally, according to the WHO Global Standards of adolescent mental health literacy, appropriate package of services and provider competencies. DESIGN AND DATA SOURCES: Systematic review of 5 databases, and screening of eligible articles, from 1 January 2008 to 31 December 2020. STUDY ELIGIBILITY CRITERIA: We focused on quantitative and mixed-method studies that evaluated adolescent mental health literacy, appropriate package of services and provider competencies in mental health services, and that targeted depression, anxiety and post-traumatic stress disorder among adolescents (10-19 years). This included adolescents exposed to interventions or strategies within mental health services. STUDY APPRAISAL AND SYNTHESIS METHODS: Study quality was assessed using the National Institutes for Health Study Quality Assessment Tools. Data were extracted and grouped based on WHO quality Standards. RESULTS: Of the 20 104 studies identified, 20 articles were included. The majority of studies came from high-income countries, with one from a low-income country. Most of the studies did not conceptualise quality. Results found that an online decision aid was evaluated to increase adolescent mental health literacy. Studies that targeted an appropriate package of services evaluated the quality of engagement between the therapist and adolescent, patient-centred communication, mental health service use, linkages to mental health services, health facility culture and intensive community treatment. Provider competencies focused on studies that evaluated confidence in managing and referring adolescents, collaboration between health facility levels, evidence-based practices and technology use. CONCLUSIONS AND IMPLICATIONS: There is limited evidence on quality measures in adolescent mental health services (as conforms to the WHO Global Standards), pointing to a global evidence gap for adolescent mental health services. There are several challenges to overcome, including a need to develop consensus on quality and methods to measure quality in mental health settings. PROSPERO REGISTRATION NUMBER: CRD42020161318.

Uniting for adolescents in covid-19 and beyond

Adolescents and young adults are also experiencing a crisis of connection to family, community, and society, with increasing numbers living on the streets or dropping out of school.34 Between 2003 and 2015, development assistance for adolescent health accounted for only 1.6% of total development assistance for health,5 despite a third of the total global burden of disease estimated to have roots in adolescence.6 Mental health problems affect 10-20% of adolescents, and many more experience symptoms that diminish wellbeing.7 Furthermore, this is the age at which the gender inequalities that underlie and pose major barriers to wellbeing emerge clearly and is when programmes can transform these inequalities. In 2017, 34% of young women and 10% of young men aged 15-24 years were not in employment, education, or training, with more pronounced disparities in northern Africa and southern Asia.68 Even among employed adolescents and young adults, an increasing proportion have poor job security, variable weekly earnings, and minimal or no health or social security coverage.8 These examples show that, as a global community, we have paid insufficient attention to the multidimensional and intersectional nature of adolescent wellbeing and the importance of the transition to young adulthood. In 2019, for a more concerted and collaborative approach to adolescents’ wellbeing, an unprecedented coalition of governments, United Nations agencies, non-governmental organisations, and academic institutions—working closely with adolescents and young people—committed to a call to action for adolescent wellbeing.9 Underpinning this call to action is a new agreed definition and conceptual framework for adolescent wellbeing to inform policies and programming.10 The framework emphasises the importance of integrating five interconnected domains in adolescent programming: good health and optimum nutrition;connectedness, positive values, and contribution to society;safety and a supportive environment;learning, competence, education, skills, and employability;and agency and resilience.

Infectious diseases in children and adolescents in China: analysis of national surveillance data from 2008 to 2017.

OBJECTIVES: To outline which infectious diseases in the pre-covid-19 era persist in children and adolescents in China and to describe recent trends and variations by age, sex, season, and province. DESIGN: National surveillance studies, 2008-17. SETTING: 31 provinces in mainland China. PARTICIPANTS: 4 959 790 Chinese students aged 6 to 22 years with a diagnosis of any of 44 notifiable infectious diseases. The diseases were categorised into seven groups: quarantinable; vaccine preventable; gastrointestinal and enteroviral; vectorborne; zoonotic; bacterial; and sexually transmitted and bloodborne. MAIN OUTCOME MEASURES: Diagnosis of, and deaths from, 44 notifiable infectious diseases. RESULTS: From 2008 to 2017, 44 notifiable infectious diseases were diagnosed in 4 959 790 participants (3 045 905 males, 1 913 885 females) and there were 2532 deaths (1663 males, 869 females). The leading causes of death among infectious diseases shifted from rabies and tuberculosis to HIV/AIDS, particularly in males. Mortality from infectious diseases decreased steadily from 0.21 per 100 000 population in 2008 to 0.07 per 100 000 in 2017. Quarantinable conditions with high mortality have effectively disappeared. The incidence of notifiable infectious diseases in children and adolescents decreased from 280 per 100 000 in 2008 to 162 per 100 000 in 2015, but rose again to 242 per 100 000 in 2017, largely related to mumps and seasonal influenza. Excluding mumps and influenza, the incidence of vaccine preventable diseases fell from 96 per 100 000 in 2008 to 7 per 100 000 in 2017. The incidence of gastrointestinal and enterovirus diseases remained constant, but typhoid, paratyphoid, and dysentery continued to decline. Vectorborne diseases all declined, with a particularly noticeable reduction in malaria. Zoonotic infections remained at low incidence, but there were still unpredictable outbreaks, such as pandemic A/H1N1 2009 influenza. Tuberculosis remained the most common bacterial infection, although cases of scarlet fever doubled between 2008 and 2017. Sexually transmitted diseases and bloodborne infections increased significantly, particularly from 2011 to 2017, among which HIV/AIDS increased fivefold, particularly in males. Difference was noticeable between regions, with children and adolescents in western China continuing to carry a disproportionate burden from infectious diseases. CONCLUSIONS: China's success in infectious disease control in the pre-covid-19 era was notable, with deaths due to infectious diseases in children and adolescents aged 6-22 years becoming rare. Many challenges remain around reducing regional inequalities, scaling-up of vaccination, prevention of further escalation of HIV/AIDS, renewed efforts for persisting diseases, and undertaking early and effective response to highly transmissible seasonal and unpredictable diseases such as that caused by the novel SARS-CoV-2 virus.